Within the 25 July 2024 upcoming board meeting papers, NSFT have released their learning from deaths report following on from the Grant Thornton review and the Forever Gone report. Due to a majority of deaths in the report being marked as unknown circumstances and unexpected deaths, this sparked outrage of the public, carers and service users as well as making national news.
You can read more about this here: https://norfolksuffolkmentalhealthcrisis.org.uk/statement-on-the-mortality-review/
Mental health campaigners respond to Norfolk and Suffolk NHS Foundation Trust: Learning from Deaths report Norfolk and Suffolk NHS Foundation Trust (NSFT) have now published their report that covers deaths across Norfolk and Suffolk from 1st April 2019 to 31st October 2023. This report comes a year after Grant Thornton, commissioned by the ICB, published the state of mortality recording and reporting at the Trust. They found that NSFT had recorded 8,440 deaths between April 2019
and October 2022 but the circumstances around these deaths were unknown- all that could be certain was that those who had died were either under the care of the trust or had been up to six months before they died.
From our understanding, NSFT’s new CEO appointed a governance and safety advisor and a team of staff who have now reviewed all deaths recorded in the Grant Thornton report, along with another year of lost lives. Whilst we recognise the time and resourcing that has gone into this piece of work, we can only urge with greater emphasis how important it is to listen to the public, carers and service users- the learning in this report has been stated before, on multiple occasions both verbally and through publications. Instead of acknowledging the concerns, individuals and groups were instead discredited, undermined and disregarded. Large numbers of staff have been used for this work- NSFT do have access to more information, but we and others have been able to come to similar conclusions using a few people and information in the public domain. We continue to keep in mind general questions surrounding deaths of patients at NSFT, given the history of misleading reporting in regards to mortality and pauses in prevention of future death reports issuing due to carefully engineered narratives. We hope NSFT themselves will be able to provide us with answers to these questions.
Whilst it is good that the Trust is now doing this piece of work that should have been done a long time ago, our concerns around another top down radical redesign remain and without full information, we are struggling to have confidence in what has been done in regards to embedding learning and change from such tragedies. As a campaign group that is consistently hearing of people being let down in the worst ways by the Trust, we are especially worried that NSFT are going to have to make 17.4 million pounds of savings this year. In the past, these cuts have been contributory to the failings people have experienced and so our faith in improvements are therefore dampened knowing the impact efficiency cuts can have on service delivery and experience of care.
After all, it is cuts that fuelled the death crisis. Without an injection of funding and additional beds, deaths will continue- this has been highlighted in the most recent prevention of future death reports issued only a few months ago. NSFT communicates their work as righting the wrongs of the past, however, we can’t help but hold onto the fact that the wrongs that have taken place have been largely preventable. The bereaved and the public are still concerned about the absence of accountability for previous harm. It is paramount these are not hidden and disregarded beneath new apparent improvements. We continue to call for an independent statutory public inquiry.
The Campaign will wait to see and feel the improvements- if learning is at the heart of this work and this is not just a counting and auditing process, we will witness a change in feedback from members, an alleviation of present unmet needs and there will be no more preventable deaths. Unfortunately, we are still reading about tragic mental health related deaths in the media, learning of the additional trauma to those who have been bereaved, hearing from carers worried about their family members safety but unable to access support and experiences of people in distress who are not receiving services.
We will continue to keep an eye on deaths at NSFT, appreciating now that the regular reporting of deaths has been reinstated in board papers. When deaths were omitted from these papers, it became hard to monitor the numbers of deaths due to this lack of transparency. However, we also bear in mind that many people die whilst waiting to even access services at NSFT – we wonder where those individuals are acknowledged. We bear in mind that some people are unsafely discharged and spend the six months post this in a signposting loop, locked out of services because they don’t fit anywhere and lose their lives later whilst stuck in the gap- we also wonder where those individuals are acknowledged. Other people fall at the first hurdle, their referral rejected and
no other appropriate options. We think of the families of those whose deaths have been subject to investigation or prevention of future death reports and still, people continue to die in similar circumstances- we wonder if that will stop any time soon or if we will hear of more heartbreak from people seeing repeated failures.
To summarise, the aim of this piece of NSFTs work is to learn from deaths. We want to hope that this is what the Trust is doing and that the reviewing of ‘legacy deaths’ was not taken forward to prove people wrong or for continued reputation protection. We want to be assured that the right questions are being asked, for the right reasons of patient safety and protection of lives of some of the most vulnerable in our society, and that this isn’t another way of the Trust attempting to spin the narrative of a mental health provider that has been failing for over a decade.
Link to Learning From Deaths Report – please read with care as the report contains details of patient deaths.
https://www.nsft.nhs.uk/download/board-of-directors-meeting-in-public-25-july-2024.pdf?ver=5312&doc=docm93jijm4n3092.pdf Pg 195, Board paper L, Agenda no. 24.42
Quick Summary of information from the report
The Key findings were that
Between April 2019 and October 2023 – 318,057 patients had contact with NSFT services.
Out of the 12,503 people that died (3.9% of the 318,057 of all patients in contact with NSFT during the review period)
-6,118 were not in scope of the review as not in receipt of care at the time of their death or within 6 months of discharge following a manual screening process
– 6,385 were under the care of NSFT or had been within six months prior to their death.
Of the 6,385 under the care of NSFT:
– 92% of people died from natural causes such as heart disease or cancer
– 56% – 3,598 expected due to natural causes (for example a person who was known to have terminal cancer before they died)
– 36% – 2,293 unexpected due to natural causes (for example a person who was known to have underlying heart disease who then died suddenly from a heart attack)
– 7% – 418 unexpected unnatural deaths
– 1% – 76 deaths unknown (either because we have not yet received a formal cause of
death and have been unable to identify if the death was natural, unnatural, expected or
unexpected based on information in the patient records, or the Coroners’ conclusion is
‘unascertained’, or the conclusion has not been released to the public)
– 14 Prevention of Future Deaths Notices were issued for deaths that occurred within this
timeframe. However, the Trust recognises it received a further 6 Prevention of Future
Deaths Notices during the review period for deaths which predated the April 2019 to
October 2023 review period.
Four High Level Themes found during the review (in bold) and sub-groups of these (in standard)
Communications
Communication and culture
Waiting times and access
Access to services / waiting times
Record keeping and processes
Poor risk assessment and planning, Observations and engagement, Record keeping, Physical health management, Medication management, Safeguarding, Poor application of policy.
Workforce
Lack of professional curiosity, Staffing and vacancies, Mental Health Capacity Act and Mental Health Act.
After looking through the report, something so fundamental like the mandatory training rates were also alarming, especially considering this is a mental health trust and not Primark…
The Trust’s current clinical risk training includes mandatory suicide prevention, Oliver McGowan
Autism Training, Safeguarding level 3 training, and physical healthcare training. Staff completion
rates for statutory and mandatory training overall sits at 91.6% (June 2024) with suicide prevention
at 98%.
A complete review of all Trust Safeguarding Children and Adults Policies has been undertaken.
The new policies were subject to an external Safeguarding expertise review from Norfolk and
Suffolk Safeguarding Partnerships and ICBs, and their feedback integrated into the revised
policies.
Mandatory Safeguarding Level 3 training for adults is at 89% compliance and for children is
at 89% compliance.
A physical health audit programme has been established for acute and community teams.
The bi-monthly inpatient audit shows overall compliance of 85% in June 2024. The quarterly audit
for community teams shows overall compliance of 72% in April 2024
After having a good read of the report, nothing is surprising, it is what the campaign has warned and shouted about for years, and what campaign members old and new have investigated themselves with a lot of time, effort and determination.
We still have an awful lot of questions to ask, and we won’t stop fighting for safe services and prevention of harm and death.
Here are the news coverage pieces from July 18 2024, from BBC Look East and ITV Anglia.